Annual Wellness Care Agreement

This agreement sets out the terms of an ongoing course of Traditional Chinese Medicine care between the clinic and its licensed practitioner ("Provider") and the patient ("Client"). It becomes effective only when BOTH parties have signed below. The Provider completes the scope and fee tables, drafts and signs first, then shares this document with the Client for review and countersignature — either in-app, or by printing, signing, and uploading a scanned copy.

Section 1 — Parties & Term

Provider (clinic / practitioner name):

Provider licence / registration number:

Client (full legal name):

Client contact email:

Care start date:

Initial term:

Section 2 — Scope of Care

During the term, the Provider will make the following services available to the Client each month:

Any care not listed in the table above is out of scope and handled under Section 5 (Additional Care & Referrals).

I have read and agree to the scope of care in this section.

Section 3 — Fees & Payment

Fees are invoiced at the start of each billing cycle and are due within 14 days of receipt. The monthly care fee is payable regardless of how many included sessions are used, in exchange for the Provider reserving capacity for the Client. Herbal formulas are billed separately as dispensed.

I have read and agree to the fee and payment terms in this section.

Section 4 — Health Goals & Safety

In your own words, what would you like this course of care to help you achieve?

Allergies, pregnancy, medications, or conditions the Provider must know about:

TCM care is complementary to — not a replacement for — conventional medical care. The Client agrees to keep the Provider informed of changes in health, medication, or pregnancy status, and to seek emergency care when appropriate.

I understand TCM care is complementary to conventional medical care and will keep the Provider informed of health changes.

Section 5 — Additional Care & Referrals

Care requested outside the scope in Section 2 is provided by agreement and billed at the additional-session rate in Section 3. The Provider may refer the Client to a physician or specialist when a condition falls outside the appropriate scope of TCM practice, and may decline requests that would be unsafe or clinically inappropriate.

I understand how additional care and referrals are handled and billed.

Section 6 — Privacy & Records

The Provider keeps the Client's health information confidential and uses it only to deliver and coordinate care, except where disclosure is required by law or authorised by the Client in writing. Clinical records are retained in accordance with applicable professional and legal requirements. The Client may request a copy of their records at any time.

I have read and agree to the privacy and records terms in this section.

Section 7 — Term, Cancellation & Renewal

After the initial term, this agreement renews automatically for successive periods of the same length unless either party gives written notice of non-renewal at least 30 days before the current period ends. Either party may end the agreement for material breach that remains uncured 14 days after written notice. On termination, the Client pays for all care delivered and capacity reserved through the effective end date.

I have read and agree to the term, cancellation, and renewal terms in this section.

Section 8 — General Acknowledgments

I have read and understood each section of this agreement.

I have had the opportunity to ask questions and seek independent advice.

I consent to electronic signatures having the same legal effect as handwritten signatures.

I am authorized to enter into this agreement on behalf of the party named above.

Section 9 — Signatures

Provider — printed name:

Date:

Client — printed name:

Date:

Optional — upload a countersigned scan of this agreement:

This template is provided for reference only and does not constitute legal or medical advice. Consult qualified counsel and follow applicable professional regulations before relying on this document.